2.0 Analysis 2.1 General Nothing was found during the investigation to suggest mechanical failure of any part of the aircraft that would have caused or contributed to the accident. Therefore, the analysis will examine ICTS, aircraft loading, company SOPs, company management, flight crew decision making, GPWS, and CFIT. 2.2 Ice-Contaminated-Tailplane Stall During both approaches, the aircraft was operating in icing conditions. If a sufficient amount of ice accumulates on the tailplane with certain aircraft configurations, ICTS can occur. The tail de-icing system functioned normally during the flight. It was determined that the crew had set the flaps to 10 degrees, which indicates that the recommended ICTS prevention procedures were being followed. Had ICTS occurred, the aircraft would have struck the ice in a steep nose-down attitude rather than a shallow impact angle, as in this accident. Therefore, it is concluded that the tailplane did not stall. 2.3 Aircraft Loading A copy of the weight and balance worksheet was not left at the departure point, nor was the worksheet found at the accident site. Therefore, it could not be established whether the aircraft's weight and balance contributed to the accident. The lack of available documentation, the apparent lack of appreciation displayed by company personnel regarding the importance of safely securing cargo, and the inadequate security of the cargo indicate that the company's load control procedures were not being followed. Improperly restrained cargo can be hazardous since cargo movement can alter the aircraft's centre of gravity or cause injury to passengers or crew. There was no indication that the cargo moved in flight. 2.4 Standard Operating Procedures The crew did not comply with the company operations manual's SOPs, thus increasing their exposure to risk during the flight. Non-adherence to SOPs is recognized as a frequent causal factor in approach and landing accidents. In this flight, SOPs, especially altitude calls, would have heightened the crew's awareness about their proximity to terrain. 2.5 Management There was no weight and balance documentation left at the departure point, which was determined to be a normal company/pilot practice, and the cargo was not properly secured before take-off. Because there was a company manager in Goose Bay to oversee the operation and to carry out or assist in aircraft loading, it is likely that the company allowed unsafe aircraft loading procedures to be followed at Goose Bay. In addition, operating the aircraft in instrument meteorological conditions under a VFR flight plan contravened the company operations manual and CAR 602.115. Such lapses by the Goose Bay operation's management were not detected by TC safety monitoring or other oversight activities. 2.6 Decision Making 2.6.1 Crew Resource Management Effective CRM enhances decision making and improves situational awareness. Both pilots had received CRM training 12 days before the accident; however, CRM techniques were not evident in their performance on the accident flight. 2.6.2 Descent Below Minimum Descent Altitude Before the second approach, the captain made a decision to descend below the MDA if visual contact with the ground was established. The aircraft did descend below MDA and struck the ground. Reports of weather conditions on the ground at the airport and the crew not acquiring the required references at MDA on the first approach indicate that the crew did not have the necessary references for descent below MDA on the second approach. The crew were preoccupied with gaining visual reference during the descent and did not adequately monitor the aircraft flight instruments. Consequently, they were unaware of their proximity to the terrain. 2.7 Terrain Warning Equipment The accident aircraft was not equipped with a GPWS, which is designed to provide a positive warning of approach to terrain. An operable GPWS would have assisted in restoring the crew's situational awareness by providing them with appropriate advisories and cues about their proximity to terrain and would have reduced the likelihood of this accident occurring. Although GPWS equipment is required on larger, passenger-carrying jet aircraft, the requirement does not extend to cargo operations, even though these operations are often conducted visually in remote areas. GPWS equipment is a recognized defence against CFIT accidents, and the absence of GPWS has been recognized by the Board as a contributory factor for approach and landing accidents. 2.8 Controlled Flight into Terrain Several of the most common factors found in other CFIT accidents were present in this occurrence. The crew did not execute a missed approach in the absence of visual cues or follow SOPs (omitted approach briefing, altitude call outs, appropriate call at MDA, and checklist items). Furthermore, they continued the approach below MDA without acquiring the necessary visual references. The absence of CRM and non-adherence to SOPs removed important defences in preventing CFIT. In this occurrence, the aircraft was capable of being controlled and was under the control of the crew until impact. Nothing indicated that the crew were aware of their proximity to the ice until shortly before impact. Consequently, this is considered to be a CFIT accident. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The captain decided to descend below the minimum descent altitude (MDA) without the required visual references. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice. 3.2 Findings as to Risk The flight crew did not follow company standard operating procedures. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight. The cargo was not adequately secured before departure, which increased the risk of injury to the crew. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation. Records establish that the aircraft departed approximately 500 pounds overweight. 3.3 Other Findings The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches. It was determined that an ice-contaminated tailplane stall did not occur. The fuel weight was not properly recorded in the journey logbook. The wreckage pattern was consistent with a controlled, shallow descent. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable. 4.0 Safety Action 4.1 Action Taken After the accident, Transport Canada (TC) conducted a regulatory audit of the operator and increased the frequency of in-flight checks and general inspection of the Goose Bay operation. 4.2 Action Required This occurrence investigation uncovered several serious deficiencies in the conduct of the mission. These deficiencies could be symptomatic of a broader and ongoing disregard for regulations and company standard operating procedures (SOPs). Indicators of the deficiencies are as follows: the presence of poor company loading practices at Goose Bay; inadequate company supervision of the Goose Bay operation; non-adherence to aircraft SOPs; and deliberate operation of the aircraft below the minimum descent altitude (MDA) when adequate visual references for landing were not present. These deviations from normal practices were present in day-to-day operations. The TSB has observed similar deficiencies in the conduct of business in other organizations, as demonstrated by the occurrences referenced in Appendix A--Supporting Documentation to Section 4.2. Common findings relating to regulatory oversight in these accidents, in general terms, were as follows: descent below MDA without adequate visual references; non-adherence to SOPs; operating under visual flight rules when in instrument meteorological conditions; operating the aircraft in an overweight condition; and inadequate company supervision of operations or maintenance. Generally, these accidents have been with smaller commercial operators or during operations in remote areas where oversight is difficult. In these operations, there were clear indications that a culture was allowed to exist in which crews and operators operated outside the safety regulations, with catastrophic consequences. It is recognized that effective safety oversight of smaller or remote operations is a challenging task. Notwithstanding this challenge, the level of acceptable risk should not be greater for passengers and crews who fly on aircraft operated by smaller operators or who operate in or into remote areas, simply because oversight is difficult. It is also recognized that there have been initiatives undertaken by TC to reduce the level of risk in these operations. However, these and other accidents indicate that more needs to be done. It appears that the traditional methods of inspection, audit, general oversight, and regulatory penalties have had limited success in fostering appropriate safety cultures in some companies and individuals; consequently, unsafe conditions continue to exist and unsafe acts are still being committed. These serious accidents indicate that some operators and crews have disregarded safety regulations and, consequently, put passengers and themselves at an unnecessary and unacceptably high level of risk. In these accidents, findings indicate that, in certain areas of commercial operations, the safety oversight efforts of TC have been somewhat ineffective. Therefore, the Board recommends that: